If patients are faced with difficult medical decisions, they usually ask the doctor for his opinion. But how is a decision made on this recommendation and what factors influence the doctor in reaching it? That was the question U.S. researchers pursued in a recent study and found out that, between recommendations given to patients and that which the doctor gives on his or her own illness, there is a big gap.
Scenario 1: Colon Cancer
Peter Ubel from Duke University and co-workers were able to show on the basis of questionnaires that making a decision about certain treatment recommendations changes the doctor’s opinion about the potential advice given. These researchers developed two scenarios: 500 primary care physicians were supposed to imagine that they themselves or their patients had gotten diagnosis for a colonic carcinoma. They were to choose one of two possible treatments. Both treatments promised healing in 80 percent of those affected, but one of the treatments had a higher treatment-related mortality, but with fewer side effects. The other treatment option had a lower risk of death, but had an increased colostomy rate, a risk of chronic diarrhea, intermittent bowel obstruction and inconsistent wound healing.
242 physicians – that is, almost half the respondents – answered the questions about treatment decisions. 37.8 percent chose for themselves the method of treatment with the increased death rate, but with lower risk of side effects. Only 24.5 percent of the doctors would recommend this treatment to their patients.
Scenario 2: Bird flu
1.600 doctors were supposed to imagine that a new strain of bird flu virus was spreading. One number of the doctors was to assume that they were infected, another number of them to proceed on the assumption that the patient was infected. Treatment with immunoglobulin was possible. Without this therapy, ten percent would die and 30 percent would have to go to hospital for a week. The treatment could reduce the complication rate by half, but could also cause death in one percent of those treated and in four percent sustained nerve damage, with paralysis as a result.
698 doctors (43.6 percent) responded, among which 62.9 percent refused immunoglobulin treatment for the infection in relation to themselves. Only 48.5 percent of the doctors had recommended to their patients rejection of the therapy.
What is the optimal decision?
Which of the decisions would be the better in individual cases is hard to say. Also, the result remains hypothetical as well as does the entire investigation, because there was indeed no real illness. Nevertheless, it appears that the process of decision making by doctors for patients or for their own person is different. For patients, this need not mean any disadvantage. It is likely that decisions about treatment recommendations for patients are made more rationally, while, with respect to decisions about themselves, feelings about fear of side effects and prolonged impairment of health play a role.
What role does the patient play in the decision?
In reality, the doctor will in the majority of cases take into account the ideas and preferences of the patients when planning the therapy. This is what one can draw as a result from a study made in 2007 on this topic. However, this study as well originates from a survey involving over 1,000 physicians and therefore may not really reflect practice.
Among the 53 percent of surveys which were actually returned, two-thirds of the doctors specified that finding a joint decision with the patients was the favoured option to take. 14 percent were rather in favour of dictating and eleven percent gave priority to the patient’s opinion. The decision-making style and the choice in itself are dependent on various factors and the patient remains in these studies the unknown quantity.